The nurse is administering heparin via the subcutaneous route. Which intervention should the nurse implement?
a. Prepare the medication using a 25-gauge, ½ inch needle
b. After injecting the needle, aspirate and observe for blood
c. After removing the needle, massage the area gently
d. Admin...
The nurse is administering heparin via the subcutaneous route. Which intervention should the nurse
implement?
a. Prepare the medication using a 25-gauge, ½ inch needle
b. After injecting the needle, aspirate and observe for blood
c. After removing the needle, massage the area gently
d. Administer the medication in the client's "love handles" - correct answer a
The nurse is administering morning medications on a medical floor. Which medication should the nurse
administer first?
a. Regular insulin sliding scale to an elderly client diagnosed with Type 1 diabetes mellitus
b. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus
c. Morphine, a narcotic analgesic, to a client diagnosed with AIDS
d. Lasix, a diuretic, to a client with hypertension - correct answer a
Which data would indicate that the antibiotic therapy has been successful for a client diagnosed with
bacterial pneumonia?
a. The client's hematocrit is within normal range
b. The client is expectorating thick green sputum
c. The client's lung sounds are clear to ausculatation
d. The client has complaints of pleuritic chest pain. - correct answer c
The nurse is administering Humalog at 0730 to a client diagnosed with Type 1 diabetes. Which
intervention should the nurse implement?
,a. Ensure the client eats at least 90% of the lunch tray
b. Do not administer unless the breakfast tray is in the client's room
c. Check the client's blood glucose level 1 hour after receiving the insulin
d. Have 50% dextrose in water at the bedside for emergency use. - correct answer b
The client has a severe anaphylactic reaction to insect bites. What priority discharge intervention should
the nurse discuss with the client?
a. Wear an insect repellent on exposed skin
b. Keep prescribed antihistamines on their person
c. Keep an EpiPen in the refrigerator at all times
d. Wear a MedicAlert identification bracelet - correct answer d
The client's mother contacts the clinic regarding medication administration stating, "My daughter
cannot swallow this capsule. It's too large." Investigation reveals that the medication is a capsule
marked SR. The nurse should instruct the mother to:
a. Open the capsule and mix the medication with apple sauce
b. Crush the medication and administer it with a glass of liquid
c. Call the pharmacist and request a change to a different medication
d. Stop the medication and inform the physician - correct answer d
The client calls the nursing station and requests pain medication. When the nurse enters the room with
the narcotic medication, the nurse finds the client laughing and talking with visitors. Which action
should the nurse administer first?
a. Administer the client's prescribed pain medication
b. Assess the client's perception of pain on a 1-10 scale
c. Wait until the visitors leave to administer any medication
,d. Check the MAR to see if there is a nonnarcotic medication ordered - correct answer b
The client in hypovolemic shock is receiving normal saline by rapid intravenous infusion. Which
assessment data would warrant immediate intervention by the nurse?
a. The client's blood pressure is 89/48
b. The client's pulse oximeter reading is 95%
c. The client's lung sounds are clear bilaterally
d. The client's urine output is 120 mL in 3 hours - correct answer a
Which intervention should the nurse implement when administering a medication via the intradermal
route?
a. Insert the needle with the bevel up at 15-degree angle in the skin
b. Prepare the medication in a 3-mL syringe using a 23-gauge 1-inch needle
c. Bunch the skin between the thumb and index finger of the nondominant hand
d. Quickly inject the medication as to not form a wheal or bleb - correct answer a
The charge nurse is observing the primary nurse administering otic drops to a 2-year-old child by pulling
down and back on the auricle. Which action should the charge nurse take?
a. Stop the primary nurse and ask the nurse to step out of the room
b. Demonstrate inserting the otic drops by pulling up and back on the auricle
c. Take no action because this is the correct way to administer the ear drops
d. Allow the nurse to administer the otic drops and then discuss the technique with the nurse - correct
answer c
The nurse prepared 2 mg of morphine for a client who is complaining of pain. When the nurse enters
the room the client tells the nurse, "I don't want to take a shot. I would like to have a pain pill." Which
action should the nurse take?
, a. Explain that the medication must be administered because it has been drawn up
b. Ask another nurse to watch the medication being wasted into the sink
c. Place the syringe in the sharps container in the client's room—
d. Notify the pharmacy that a narcotic was not administered to the client - correct answer b
The nurse is preparing to adminster 3 mL of a medication intramuscularly to an adult client in the clinic.
Which muscle is the best site to administer the medication?
a. The deltoid muscle
b. The dorsogluteal muscle
c. The ventrogluteal muscle
d. The vastus lateralis muscle - correct answer c
The nurse is administering medications through a gastrostomy tube (GT). Which intervention should the
nurse implement first?
a. Place the crushed pills in the gastrostomy tube.
b. Flush the gastrostomy with at least 30 mL of tap water
c. Use the plunger to push the medication into the GT
d. Clamp the gastrostomy tube closed. - correct answer b
The charge nurse is making rounds on the clients and notices the primary nurse left a medication cup
with three tablets at the client's bedside. Which action should the charge nurse implement?
a. Administer the client's medications
b. Remove the medication cup from the room
c. Request the primary nurse come to the room
d. Leave the cup at the bedside and talk to the primary nurse - correct answer b
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